Chondrosarcoma of the Chest Wall: A Single Institution Review of 50 Cases.

INTRODUCTION: Chondrosarcoma (CS) is most common primary osseous tumor of the chest wall. The aim of this study was to report results from surgical procedures and evaluate clinical factors predicting survival of patients with chest wall CSs treated in a single tertiary sarcoma center. MATERIALS AND METHODS: Fifty patients with primary CS located in the ribs and sternum were included. Details of the clinical data and oncological outcomes, including local recurrence (LR) and disease-specific survival (DSS), were collected. RESULTS: The tumor was primarily originated in the sternum in 6 patients (12.5%) and in ribs 2 to 11 in the remaining patients. Specimens were histologically graded 1 in 13 patients (26%), 2 in 28 (56%), 3 in 8 (16%), and 1 (2%) as mesenchymal grade 3 CS. R0 margins were obtained in all cases. Reconstruction was warranted in 47 (94%) cases. Local recurrence developed in 3 (6%) patients, and the median time to LR was 17 (range, 16-68) months. Eight (16%) patients developed metastasis. Increasing tumor volume was a statistically significant factor for reduction of DSS. CONCLUSIONS: Chondrosarcoma of the chest wall can be treated effectively with clear margins, resulting in lower LR rate and higher DSS than CS of the extremities and pelvis. Metastasis of the chest wall mostly occurs in high-grade tumors, and the locations of the metastases differ greatly from those observed in CS of the extremities and pelvis. Metastases are commonly extrapulmonary, indicating the need for postoperative follow-up with multiple imaging modalities to monitor recurrence and metastases.

Visual Counting and Automated Image-analytic Assessment of Ki-67 and their Prognostic Value in Synovial Sarcoma.

Background: Ki-67 is a widely used proliferation marker reflecting prognosis in various tumors. However, visual assessment and scoring of Ki-67 suffers from marked inter-observer and intra-observer variability. We aimed to assess the concordance of manual counting and automated image-analytic scoring methods for Ki-67 in synovial sarcoma. Patients and Methods: Tissue microarrays from 34 patients with synovial sarcoma were immunostained for Ki-67 and scored both visually and with 3DHistech QuantCenter. Results: The automated assessment of Ki-67 expression was in good agreement with the visually counted Ki-67 (r Pearson =0.96, p<0.001). In a Cox regression model automated [hazard ratio (HR)=1.047, p=0.024], but not visual (HR=1.063, p=0.053) assessment method associated high Ki-67 scores with worse overall survival. Conclusion: The automated Ki-67 assessment method appears to be comparable to the visual method in synovial sarcoma and had a significant association to overall survival.

Soft Tissue Sarcoma of Lower Extremity: Functional Outcome and Quality of Life.

BACKGROUND: Few studies have focused on patient-related factors in analyzing long-term functional outcome and health-related quality of life (HRQoL) in patients with postoperative lower extremity soft tissue sarcoma (STS). OBJECTIVE: The purpose of this study was to investigate factors associated with postoperative functional outcome and HRQoL in patients with lower extremity STS. METHODS: This cross-sectional study was performed in a tertiary referral center using the Toronto Extremity Salvage Score (TESS), Quality-of-Life Questionnaire (QLQ)-C30 and 15 Dimension (15D) measures. Functional outcome and HRQoL data were collected prospectively. All patients were treated by a multidisciplinary team according to a written treatment protocol. RESULTS: A total of 141 patients who had undergone limb-salvage surgery were included. Depending on the outcome measure used, 19-51% of patients were completely asymptomatic and 13-14% of patients had an unimpaired HRQoL. The mean score for TESS, 15D mobility score, and QLQ-C30 Physical Functioning scale were 86, 0.83, and 75, respectively, while the mean score for 15D was 0.88, and 73 for QLQ-C30 QoL. Lower functional outcome was statistically significantly associated with higher age, higher body mass index (BMI), and the need for reconstructive surgery and radiotherapy, while lower HRQoL was statistically significantly associated with higher age, higher BMI, and reconstructive surgery. CONCLUSION: Functional outcome and HRQoL were generally high in this cross-sectional study of patients with STS in the lower extremity. Both tumor- and treatment-related factors had an impact but patient-related factors such as age and BMI were the major determinants of both functional outcome and HRQoL.

Further validation of the Toronto extremity salvage score for lower extremity soft tissue sarcoma based on Finnish patients.

The most widely used patient-reported outcome (PRO) measure for soft tissue sarcoma (STS) patients is the Toronto Extremity Salvage Score (TESS). The aim of the study was to validate and test the reliability of the TESS for patients with lower extremity STS based on Finnish population data. Patients were assessed using the TESS, the QLQ-C30 Function and Quality of life (QoL) modules, the 15D and the Musculoskeletal tumour Society (MSTS) score. The TESS was completed twice with a 2- to 4-week interval. The intraclass correlation coefficient (ICC) was used for test-retest reliability. Construct validity was tested for structural validity and convergent validity. Altogether 136 patients completed the TESS. A ceiling effect was noted as 21% of the patients scored maximum points. The ICC between first and second administration of the TESS was 0.96. The results of exploratory factor analysis together with high Cronbach's alpha (0.98) supported a unidimensional structure. The TESS correlated moderately with the MSTS score (rho = 0.59, p< 0.001) and strongly with the mobility dimension in the 15D HRQL instrument (rho = 0.76, p < 0.001) and the physical function in QLQ-C30 (rho = 0.83, p< 0.001). The TESS instrument is a comprehensive and reliable PRO measure. The TESS may be used as a validated single index score, for lower extremity STS patients for the measurement of a functional outcome. The TESS seems to reflect patients' HRQoL well after the treatment of lower extremity soft tissue sarcomas.

Assessment of the structural validity of three foot and ankle specific patient-reported outcome measures.

BACKGROUND: The structural validity of the Lower extremity functional scale (LEFS), the Visual analogue scale foot and ankle (VAS-FA), and the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) has not been compared earlier in patients after foot and ankle surgery. METHODS: Altogether 165 previously operated patients completed the foot and ankle specific instruments, the 15D health-related quality of life (HRQoL) instrument, and general health (VAS). RESULTS: The LEFS, the VAS-FA and the WOMAC had slight differences in their measurement properties. The VAS-FA had the best targeting and coverage. All three foot and ankle measures accounted for mobility and usual activities when compared to the different aspects of generic HRQoL. CONCLUSIONS: The LEFS, the VAS-FA and the WOMAC have relatively similar psychometric properties among foot and ankle patients, yet the VAS-FA provides the best targeting and coverage.

Rasch analysis of the Lower Extremity Functional Scale for foot and ankle patients.

Purpose: The Lower Extremity Functional Scale (LEFS) is a widely used 20-item patient-reported outcome instrument with five response categories. We investigated the measurement properties of the Finnish version of the LEFS among foot and ankle patients to refine the scale to measure more accurately what is relevant for patients.Materials and methods: Data were obtained from 182 patients who had undergone foot and ankle surgery for various reasons. The Rasch Measurement Theory and Cronbach's alpha were employed for analyses of model and item fit, response category thresholds, targeting, person separation index, and internal consistency.Results: Threshold misfit was noted in 13 of the 20 items. After collapsing the response categories 1 ("Quite a bit of difficulty") and 2 ("Moderate difficulty"), five items were removed one by one to make the scale fit the model. This new 15-item scale with four response categories had a unidimensional structure with good item fit, ordered thresholds, and good coverage/targeting. The person separation index and Cronbach's alpha were 0.85 and 0.95, respectively.Conclusions: This study provides a new 15-item LEFS with four response categories for clinicians and researchers to measure function in foot and ankle patients in a relevant way.Implications for rehabilitationAssessing foot and ankle function and rehabilitation effectiveness is of high importance.The Lower Extremity Functional Scale (LEFS) is a widely used 20-item patient-reported outcome instrument with five response categories.The Finnish LEFS was revised to better fit into the Rasch model.The new LEFS with 15 items and four response categories for foot and ankle patients is a psychometrically sound, meaningful, and operable instrument.

Toward a Consensus on Centralization in Surgery.

OBJECTIVES: To critically assess centralization policies for highly specialized surgeries in Europe and North America and propose recommendations. BACKGROUND/METHODS: Most countries are increasingly forced to maintain quality medicine at a reasonable cost. An all-inclusive perspective, including health care providers, payers, society as a whole and patients, has ubiquitously failed, arguably for different reasons in environments. This special article follows 3 aims: first, analyze health care policies for centralization in different countries, second, analyze how centralization strategies affect patient outcome and other aspects such as medical education and cost, and third, propose recommendations for centralization, which could apply across continents. RESULTS: Conflicting interests have led many countries to compromise for a health care system based on factors beyond best patient-oriented care. Centralization has been a common strategy, but modalities vary greatly among countries with no consensus on the minimal requirement for the number of procedures per center or per surgeon. Most national policies are either partially or not implemented. Data overwhelmingly indicate that concentration of complex care or procedures in specialized centers have positive impacts on quality of care and cost. Countries requiring lower threshold numbers for centralization, however, may cause inappropriate expansion of indications, as hospitals struggle to fulfill the criteria. Centralization requires adjustments in training and credentialing of general and specialized surgeons, and patient education. CONCLUSION/RECOMMENDATIONS: There is an obvious need in most areas for effective centralization. Unrestrained, purely "market driven" approaches are deleterious to patients and society. Centralization should not be based solely on minimal number of procedures, but rather on the multidisciplinary treatment of complex diseases including well-trained specialists available around the clock. Audited prospective database with monitoring of quality of care and cost are mandatory.

Oncologic Resection and Reconstruction of the Chest Wall: A 19-Year Experience in a Single Center.

BACKGROUND: The aim of this study was to analyze chest wall reconstruction following oncologic resection performed by a single surgeon over a 19-year period. METHODS: A retrospective review was performed for 135 patients who underwent oncologic chest wall resection from 1997 to 2015. RESULTS: Average patient age was 57.8 years. Indications for resection were advanced breast cancer (n = 44), soft-tissue sarcoma (n = 38), bone sarcoma or chondrosarcoma (n = 28), desmoid tumor (n = 11), metastasis from other cancers (n = 7), and other primary tumors (n = 7). There were 72 full-thickness and 63 partial-thickness resections (34 soft-tissue resections only and 29 skeletal bone resections only). Resection margins were wide (n = 29), marginal (n = 82), and intralesional (n = 24). Reconstruction was warranted in 118 cases: chest wall stabilization and flap coverage in 57, chest wall stabilization only in 36, and soft-tissue flap coverage only in 25 cases. In total, 82 flaps were performed (17 free flaps and 65 pedicled/local flaps). There were no perioperative mortalities or flap losses. Complications occurred in 29 operations (Clavien-Dindo classifications grade II, n = 12; grade IIIa, n = 4; grade IIIb, n = 10; and grade IVa, n = 3) and 19 reoperations were necessary. Median follow-up was 49 months. Survival was calculated by the Kaplan-Meier method. One-, 2-, and 5-year survival rates were 84, 82, and 70 percent, respectively. CONCLUSION: With careful patient selection, appropriate perioperative and postoperative care, and accurate surgical technique, even extensive chest wall resections and reconstructions are safe. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reliability and validity of the Finnish version of the Visual Analogue Scale Foot and Ankle (VAS-FA).

BACKGROUND: There have previously been no validated foot and ankle-specific patient-reported outcome measures in Finnish. METHODS: The Visual Analogue Scale Foot and Ankle (VAS-FA) was translated and adapted into Finnish. Thereafter, 165 patients who had undergone foot and ankle surgery completed a questionnaire set on two separate occasions. Analyses included testing of floor-ceiling effect, internal consistency, reproducibility, and validity. RESULTS: Minor linguistic differences emerged during the translation. Some structural adjustments were made. The mean (SD) total VAS-FA score was 74 (23). In the three subscales, maximum scores were noted in 2-5% of the responses, and internal consistency ranged from 0.81 to 0.94. Reproducibility was excellent (ICC, 0.97). The total VAS-FA score correlated significantly with the Lower Extremity Functional Scale (r=0.84) and the 15D Mobility dimension (r=0.79). The VAS-FA loaded on two factors (pain/movement and problems/limitations). CONCLUSIONS: The Finnish version of the VAS-FA has high reliability and strong validity.

Improved prognosis in soft-tissue sarcoma of extremity and trunk wall.

Background and purpose - Soft-tissue sarcoma (STS) is rare, with challenging individualized treatment, so diagnostics and treatment should be centralized. Historical controls are sometimes used for investigation of whether new diagnostic or therapeutic tools affect patient outcome. However, as yet unknown factors may affect the outcome. We investigated prognostic factors and prognosis in 2 nationwide cohorts of patients diagnosed with a local STS during the periods 1998-2001 and 2005-2010, with special interest in finding factors lying behind possible improvement of prognosis. Patients and methods - 2 cohorts of patients with STS of the extremities or trunk diagnosed during the periods 1998-2001 and 2005-2010 were retrieved from the nationwide Finnish Cancer Registry. Detailed information was gathered from patient files. Results - Compared to first cohort, a larger proportion of patients with inadequate surgery in the second cohort received radiation therapy, and both the local control rate and the sarcoma-specific survival rate improved in the second cohort. For sarcoma-specific survival, cohort (HR =0.6, 95% CI: 0.5-0.9), age, depth, grade, and margin were significant factors in multivariate analysis. For local control, cohort (HR =0.6, 95% CI: 0.5-0.9), age, and margin were significant in multivariate analysis. Interpretation - Known prognostic factors including type of treatment did not entirely explain the secular trend of continuous improvement in prognosis in STS. This illustrates the danger of using historical controls for investigation of whether new diagnostic or therapeutic tools have an effect on patient outcome.

Reliability and validity of the Finnish version of the Lower Extremity Functional Scale (LEFS).

PURPOSE: The present study aimed to assess the psychometric properties of the Finnish version of the Lower Extremity Functional Scale (LEFS) among foot and ankle patients. METHODS: The LEFS was translated and cross-culturally adapted to Finnish. We assessed the test-retest reliability, internal consistency, floor-ceiling effect, construct validity and criterion validity in patients who underwent surgery due to musculoskeletal pathology of the foot and ankle (N = 166). RESULTS: The test-retest reliability was high (ICC = 0.93, 95% CI: 0.91-0.95). The standard error of measurement was 4.1 points. The Finnish LEFS showed high internal consistency (Cronbach's α = 0.96). A slight ceiling effect occurred as 17% achieved the maximum score. The LEFS correlation was strong with the 15D Mobility dimension (r = 0.74) and overall HRQoL (r = 0.66), pain during foot and ankle activity (r= -0.69) and stiffness (r= -0.62). LEFS correlated moderately with foot and ankle pain at rest (r= -0.50) and with physical activity (r = 0.46). CONCLUSIONS: The Finnish version of the LEFS showed reliability and validity comparable to those of the original version. This study indicates that the Finnish version of the LEFS serves both clinical and scientific purposes in assessing lower-limb function. Implications for Rehabilitation The Finnish version of the Lower Extremity Functional Scale (LEFS) is a reliable and valid tool for assessing lower-extremity musculoskeletal disability in Finnish-speaking population. Investigation of the psychometric properties of the Finnish version of the LEFS showed validity and reliability comparable to those of the original English version. The Finnish LEFS is easy to complete and suitable for clinical, rehabilitation and research purposes.

The desmoid tumour: local control after surgical treatment.

Desmoid tumours are uncommon non-malignant tumours that show a locally aggressive growth pattern and a high local recurrence rate after surgery. Approximately 10% of the desmoid tumours are associated with familial adenomatous polyposis (FAP). Variable natural history of the disease challenges treatment decision-making in the absence of prospective, randomised data. Association of this rare tumour to GIST is speculated and the tumorigenesis may share common steps. This study reviews given treatment and reports prognostic factors for local control and concurrent neoplasms in patients evaluated by a single soft tissue tumour group. Patients referred to the soft tissue tumour group at Helsinki University Central Hospital (HUCH) for a desmoid tumour (primary or recurred) during 1987-2007 and receiving surgical treatment with or without adjuvant treatment were included in this retrospective review. All locations and also patients with a FAP-associated tumour were included. Extra-abdominal location showed lower local control despite the fact that 27% of patients also received radiation therapy. One amputation was performed. Female sex and location in the rectus abdominis muscle predicted improved local control in multivariate analysis. In this review, the occurrence (14%) of concurrent neoplasms was higher than expected with unusual tumour types noted including two GISTs. In those patients in whom surgical treatment is chosen, adjuvant radiation therapy should also be considered in order to decrease morbidity from aggressive surgery aiming at R0 resection. Further studies are suggested to illuminate the biological association between the desmoid tumour and other neoplasms.

Marginal miss or radioresistance? The pattern of local recurrence after operation and 3D planned radiation treatment in soft tissue sarcoma of the extremities and the limb girdles; an analysis based on image fusion.

BACKGROUND: Most local recurrences have developed in the clinical target volume in previously published series after combined modality treatment for soft tissue sarcoma. However, marginal misses were seen in almost 20% of the patients. The aim of the present study was to determine the location of the recurrence and the total dose at the centre point of the local recurrence for future radiation therapy planning. MATERIAL AND METHODS: We included only patients with images in digital form, during 1999-2006 (n = 17), treated for soft tissue sarcoma with combined surgical therapy and radiotherapy at Helsinki University Central Hospital. Image fusion was used to determine the location of the recurrence in relation to radiation therapy target. RESULTS: In the present study utilising digital image fusion, in patients with 3D CT-based radiation treatment planning the risk of marginal miss was low as only one patient of 17 relapsed outside the target. Estimated mean radiation dose at the site of local recurrence was 49.1 Gy in patients with positive margins and 48.1 Gy in patients with negative margins. CONCLUSION: The risk of marginal miss in soft tissue sarcoma is low after modern 3D planned radiation treatment combined with surgery. More generous use of boost might improve in-target local control.

Soft tissue sarcoma - a population-based, nationwide study with special emphasis on local control.

BACKGROUND: A prospective diagnostics and treatment protocol for extremity and trunk wall soft tissue sarcoma (STS) was introduced by the Scandinavian Sarcoma Group in 1986 and it was also widely adopted in Finland. We have updated the protocol and made it more detailed at the Helsinki University Central Hospital. We retrospectively compared diagnostics and treatment of STS in a nationwide population-based material to this protocol with special emphasis on local control. METHODS: Data for 219 patients with an STS of extremity or trunk wall diagnosed during 1998-2001 was retrieved from the nationwide Finnish Cancer Registry. Histologic review was performed. Treatment centres were divided into high-, intermediate- and low-volume centres based on the number of patients with final surgery during the study period. RESULTS: Significantly more patients were operated with a preoperative histological or cytological diagnosis at high-volume centres. No preoperative diagnosis was a strong predictor for the patient to undergo more than one operation (p < 0.0001). Wide surgical margin was achieved more often at high-volume centres, but in all centre categories a considerable percentage of patients with inadequate surgical margin did not receive adjuvant radiation therapy. Local control at five years was 82% at high-volume centres, 61% at intermediate-volume centres treating highest percentage of deep tumours and 69% at low-volume centres (p = 0.046). Local control improved as the number of patients operated (surgical volume of the centre) increased. CONCLUSION: The present quality-control study is the first nationwide population-based study to assess diagnostics and treatment of STS. When referred to a specialised sarcoma centre even patients with inadequate surgery can achieve good local control. STS is a rare cancer and its treatment should be centralised in Finland, which has 5.4 million inhabitants and approximately 100 new STSs of extremities and trunk wall annually.

The cost utility of reduction mammaplasty at medium-term follow-up: a prospective study.

PURPOSE: The effects of reduction mammaplasty (RM) have been proved in several randomised trials. However, publications regarding cost utility are infrequent and lacking with regard to medium-term follow-up. Therefore, we decided to assess the cost utility of RM at 2-5 years' follow-up, when later costs and possible re-operations have been incurred. METHODS: A total of 73 patients had bilateral RM between January 2005 and March 2007 in the Hospital District of Helsinki and Uusimaa, Finland. Health-related quality of life was measured with the 15D. Preoperative data were collected with an interview at an appointment and follow-up data by means of a postal survey. Direct hospital costs were obtained from the Ecomed(®) clinical patient administration database (Datawell Ltd., Espoo, Finland). RESULTS: A total of 62 (85%) patients agreed to participate in the study and returned the follow-up questionnaire. The mean follow-up time was 4.0 years (SD 0.53, range 2.3-4.6 years). The mean improvement in the 15D score change was 0.083 (SD 0.081). The mean number of quality-adjusted life years (QALYs) gained was 3.052 (SD 3.167, range 2.561-17.553). The mean hospital costs of the intervention were €3601 (SD 1321), and the mean cost per QALY gained was €1180. Roughly 76% of the costs were due to the hospital stay during the operation. Eight percent of the costs were incurred more than 6 months after the hospital stay. CONCLUSIONS: The cost per QALY gained by RM is low, even when considering later costs caused by possible re-operations, and compares favourably with a number of other surgical procedures.

The outcome of reduction mammaplasty remains stable at 2-5 years' follow-up: a prospective study.

PURPOSE: Several randomised studies have proved the effectiveness of reduction mammaplasty in short-term follow-up. However, medium-term prospective follow-up studies are rare. Therefore, a prospective study was conducted to assess the medium-term results and to see whether there are any changes in the intervention effect during the first years. METHODS: A total of 73 patients were operated on between January 2005 and March 2007. Patients completed the 15D health-related quality-of-life questionnaire, The Finnish Breast-Associated Symptoms (FBAS) questionnaire and Raitasalo's modification of the short form of the Beck Depression Inventory (RBDI). In July 2009, follow-up data was collected by postal mail. RESULTS: As many as 62 patients (85%) agreed to participate in the study and returned the follow-up data. Non-responders did not differ from responders in baseline characteristics. Mean follow-up time was 4.0 years (range, 2.3-4.6). Preoperatively, patients had significantly inferior quality of life when compared with the age-standardised population (p < 0.001). This health burden was removed after reduction mammaplasty. At follow-up, patients had significantly better quality of life, less breast-associated symptoms, less depression and anxiety and better self-esteem when compared with the preoperative situation (p < 0.001). CONCLUSIONS: Reduction mammaplasty results in remarkable alleviation in breast-associated and psychological symptoms, and improvement in quality of life. This remains clearly significant and stable at 2-5 years follow-up.

Vascular invasion is an early event in pathogenesis of Merkel cell carcinoma.

This study investigated vascular and especially lymphovascular invasion in primary Merkel cell carcinoma and its value as a prognostic factor. Paraffin-embedded blocks prepared from tumor samples obtained from 126 patients diagnosed with Merkel cell carcinoma in 1979-2004 were immunohistochemically stained using antibodies CD31 and D2-40 to detect intravascular tumor emboli. This finding was compared with the clinical data and the disease outcome. Intravascular tumor cells were observed in 117 (93%) of the samples. The majority, 83 (66%), showed only lymphovascular invasion. Only blood vascular invasion was seen in four (3%) samples. In all, 30 (24%) samples demonstrated both lymphovascular invasion and blood vascular invasion. In only nine (7%) samples, there was no invasion within the vascular structures. The tumors lacking invasion were significantly smaller (P<0.01 and alpha=0.050) than those with vascular invasion, although lymphovascular invasion was observed even in the smallest tumor (0.3 cm) of this study. Already in the early stages of the disease, Merkel cell carcinoma seems to have the capacity to penetrate vessel walls. Our finding of the high frequency of lymphovascular invasion might therefore explain the extremely aggressive clinical behavior of Merkel cell carcinoma. This may support the role of sentinel node biopsy even in the case of very small primary Merkel cell carcinoma tumors.

Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures.

BACKGROUND: The treatment of open tibial shaft fractures remains controversial. Important considerations in surgical management include surgical timing, fixation technique and soft tissue coverage. This study was performed to evaluate the results of acute surgical debridement, unreamed nailing and soft tissue reconstruction in the treatment of severe open tibial shaft fractures. PATIENTS AND METHODS: During a 10-year period between January 1993 and July 2002, 927 tibial shaft fractures were treated with interlocking intramedullary nails. Among them, there were 19 consecutive patients with Gustilo type IIIB to IIIC open tibial shaft fractures with extensive soft tissue injury needing a muscle flap coverage and being suitable for intramedullary nailing. All 19 patients were called for a late follow-up which was conducted with a physical examination and a radiographic and functional outcome assessment. The radiographs were reviewed to determine the fracture healing time and the final alignment. RESULTS: All 19 open fractures with severe soft tissue injury healed without any infection complications. The fractures united in a mean of 8 months. Nine patients had delayed fracture healing (union time over 24 weeks). One of these patients needed exchange nailing, one patient autogenous bone grafting and dynamisation on the nail and seven patients needed dynamisation of the nail before the final fracture healing. In all patients, the alignment was well maintained. However, seven patients had shortening of the tibia by 1-2 cm and two of them also external rotation of 10 degrees . The functional outcome was good in 18/19 patients. INTERPRETATION: Acute surgical debridement, unreamed interlocking intramedullary nailing and soft tissue reconstruction with a muscle flap appear to be a safe and effective method of treatment for Gustilo type IIIB open tibial shaft fractures.

Distally-based peroneus brevis muscle flap: a successful way of reconstructing lateral soft tissue defects of the ankle.

Sixteen distally-based peroneus brevis muscle flaps were used to cover soft tissue defects in the lateral side of the ankle. The defect in 13 cases was on the lateral malleolus, in two on the lateral side of the calcaneus, and in one case in the Achilles tendon. The patients were all followed up until full recovery (mean 7.6 months, range 1.5-22 months). One flap failed to cover the defect and was replaced with a microvascular latissimus dorsi flap. In three cases minor revision and new skin grafting of the distal end of the flap was necessary. In 15 of the 16 patients the distally-based peroneus brevis muscle was successful in covering the lateral defect in the ankle. The technique of harvesting a flap is reliable, fast, and the overall success of the flap is good. The flap is particularly suitable for covering small or moderate sized defects on the lateral malleolus.

Reconstruction of soft tissue after complicated calcaneal fractures.

A total of 35 flap reconstructions were done to cover exposed calcaneal bones in 31 patients. All patients had calcaneal fractures, 19 of which were primarily open. Soft tissue reconstruction for the closed fractures was indicated by a postoperative wound complication. A microvascular flap was used for reconstruction in 21 operations (gracilis, n = 11; anterolateral thigh, n = 5; rectus abdominis, n = 3; and latissimus dorsi, n = 2). A suralis neurocutaneous flap was used in eight, local muscle flaps in three, and local skin flaps in three cases. The mean follow-up time was 14 months (range 3 months-4 years). One suralis flap failed and was replaced by a latissimus dorsi flap. Necrosis of the edges that required revision affected three flaps. Deep infection developed in two patients and delayed wound healing in another four. During the follow-up the soft tissues healed in all patients and there were no signs of calcaneal osteitis. Flaps were considered too bulky in five patients. Soft tissues heal most rapidly with microvascular flaps. In the long term, gracilis muscle covered with free skin grafts gives a good contour to the foot. The suralis flap is reliable and gives a good final aesthetic outcome. Local muscles can be transposed for reconstruction in small defects.